Basic Information
| Provider Information | |||||||||
| NPI: | 1184004103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKLIN | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | EVE MICKELSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICKELSON | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | EVE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4720 NELSON BROGDON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUGAR HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709451990 | ||||||||
| FaxNumber: | 9106780115 | ||||||||
| Practice Location | |||||||||
| Address1: | 4720 NELSON BROGDON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUGAR HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709451990 | ||||||||
| FaxNumber: | 9106780115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 209826 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 79851 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.